Predicting clinical outcomes from preclinical data is essential for identifying safe and effective drug combinations, reducing late-stage clinical failures, and accelerating the development of precision therapies. Current AI models rely on structural or target-based features but fail to incorporate the multimodal data necessary for accurate, clinically relevant predictions. Here, we introduce Madrigal, a multimodal AI model that learns from structural, pathway, cell viability, and transcriptomic data to predict drug-combination effects across 953 clinical outcomes and 21,842 compounds, including combinations of approved drugs and novel compounds in development. Madrigal uses an attention bottleneck module to unify preclinical drug data modalities while handling missing data during training and inference, a major challenge in multimodal learning. It outperforms single-modality methods and state-of-the-art models in predicting adverse drug interactions, and ablations show both modality alignment and multimodality are necessary. It captures transporter-mediated interactions and aligns with head-to-head clinical trial differences for neutropenia, anemia, alopecia, and hypoglycemia. In
Adverse drug reaction (ADR) prediction plays a crucial role in both health care and drug discovery for reducing patient mortality and enhancing drug safety. Recently, many studies have been devoted to effectively predict the drug-ADRs incidence rates. However, these methods either did not effectively utilize non-clinical data, i.e., physical, chemical, and biological information about the drug, or did little to establish a link between content-based and pure collaborative filtering during the training phase. In this paper, we first formulate the prediction of multi-label ADRs as a drug-ADR collaborative filtering problem, and to the best of our knowledge, this is the first work to provide extensive benchmark results of previous collaborative filtering methods on two large publicly available clinical datasets. Then, by exploiting the easy accessible drug characteristics from non-clinical data, we propose ADRNet, a generalized collaborative filtering framework combining clinical and non-clinical data for drug-ADR prediction. Specifically, ADRNet has a shallow collaborative filtering module and a deep drug representation module, which can exploit the high-dimensional drug descriptors
In the context of clinical research, computational models have received increasing attention over the past decades. In this systematic review, we aimed to provide an overview of the role of so-called in silico clinical trials (ISCTs) in medical applications. Exemplary for the broad field of clinical medicine, we focused on in silico (IS) methods applied in drug development, sometimes also referred to as model informed drug development (MIDD). We searched PubMed and ClinicalTrials.gov for published articles and registered clinical trials related to ISCTs. We identified 202 articles and 48 trials, and of these, 76 articles and 19 trials were directly linked to drug development. We extracted information from all 202 articles and 48 clinical trials and conducted a more detailed review of the methods used in the 76 articles that are connected to drug development. Regarding application, most articles and trials focused on cancer and imaging-related research while rare and pediatric diseases were only addressed in 14 articles and 5 trials, respectively. While some models were informed combining mechanistic knowledge with clinical or preclinical (in-vivo or in-vitro) data, the majority of
The extraction of pharmacological knowledge from regulatory documents has become a key focus in biomedical natural language processing, with applications ranging from adverse event monitoring to AI-assisted clinical decision support. However, research in this field has predominantly relied on English-language corpora such as DrugBank, leaving a significant gap in resources tailored to other healthcare systems. To address this limitation, we introduce DART (Drug Annotation from Regulatory Texts), the first structured corpus of Italian Summaries of Product Characteristics derived from the official repository of the Italian Medicines Agency (AIFA). The dataset was built through a reproducible pipeline encompassing web-scale document retrieval, semantic segmentation of regulatory sections, and clinical summarization using a few-shot-tuned large language model with low-temperature decoding. DART provides structured information on key pharmacological domains such as indications, adverse drug reactions, and drug-drug interactions. To validate its utility, we implemented an LLM-based drug interaction checker that leverages the dataset to infer clinically meaningful interactions. Experiment
We introduce an expert curated, real-world benchmark for evaluating document-grounded question-answering (QA) motivated by generic drug assessment, using the U.S. Food and Drug Administration (FDA) drug label documents. Drug labels contain rich but heterogeneous clinical and regulatory information, making accurate question answering difficult for current language models. In collaboration with FDA regulatory assessors, we introduce FDARxBench, and construct a multi-stage pipeline for generating high-quality, expert curated, QA examples spanning factual, multi-hop, and refusal tasks, and design evaluation protocols to assess both open-book and closed-book reasoning. Experiments across proprietary and open-weight models reveal substantial gaps in factual grounding, long-context retrieval, and safe refusal behavior. While motivated by FDA generic drug assessment needs, this benchmark also provides a substantial foundation for challenging regulatory-grade evaluation of label comprehension. The benchmark is designed to support evaluation of LLM behavior on drug-label questions.
Clinical trials are an indispensable part of the drug development process, bridging the gap between basic research and clinical application. During the development of new drugs, clinical trials are used not only to evaluate the safety and efficacy of the drug but also to explore its dosage, treatment regimens, and potential side effects. This review discusses the various stages of clinical trials, including Phase I (safety assessment), Phase II (preliminary efficacy evaluation), Phase III (large-scale validation), and Phase IV (post-marketing surveillance), highlighting the characteristics of each phase and their interrelationships. Additionally, the paper addresses the major challenges encountered in clinical trials, such as ethical issues, subject recruitment difficulties, diversity and representativeness concerns, and proposes strategies for overcoming these challenges. With the advancement of technology, innovative technologies such as artificial intelligence, big data, and digitalization are gradually transforming clinical trial design and implementation, improving trial efficiency and data quality. The article also looks forward to the future of clinical trials, particularly
Drug repurposing has attracted increasing attention from both the pharmaceutical industry and the research community. Many existing computational drug repurposing methods rely on preclinical data (e.g., chemical structures, drug targets), resulting in translational problems for clinical trials. In this study, we propose a clinical connectivity map framework for drug repurposing by leveraging laboratory tests to analyze complementarity between drugs and diseases. We establish clinical drug effect vectors (i.e., drug-laboratory test associations) by applying a continuous self-controlled case series model on a longitudinal electronic health record data. We establish clinical disease sign vectors (i.e., disease-laboratory test associations) by applying a Wilcoxon rank sum test on a large-scale national survey data. Finally, we compute a repurposing possibility score for each drug-disease pair by applying a dot product-based scoring function on clinical disease sign vectors and clinical drug effect vectors. We comprehensively evaluate 392 drugs for 6 important chronic diseases (e.g., asthma, coronary heart disease, type 2 diabetes, etc.). We discover not only known associations between
Drug repurposing identifies new therapeutic uses for existing drugs, reducing the time and costs compared to traditional de novo drug discovery. Most existing drug repurposing studies using real-world patient data often treat the entire population as homogeneous, ignoring the heterogeneity of treatment responses across patient subgroups. This approach may overlook promising drugs that benefit specific subgroups but lack notable treatment effects across the entire population, potentially limiting the number of repurposable candidates identified. To address this, we introduce STEDR, a novel drug repurposing framework that integrates subgroup analysis with treatment effect estimation. Our approach first identifies repurposing candidates by emulating multiple clinical trials on real-world patient data and then characterizes patient subgroups by learning subgroup-specific treatment effects. We deploy \model to Alzheimer's Disease (AD), a condition with few approved drugs and known heterogeneity in treatment responses. We emulate trials for over one thousand medications on a large-scale real-world database covering over 8 million patients, identifying 14 drug candidates with beneficial e
Drug representations have played an important role in cheminformatics. However, in the healthcare domain, drug representations have been underused relative to the rest of Electronic Health Record (EHR) data, due to the complexity of high dimensional drug representations and the lack of proper pipeline that will allow to convert clinical drugs to their representations. Time-varying vital signs, laboratory measurements, and related time-series signals are commonly used to predict clinical outcomes. In this work, we demonstrated that using clinical drug representations in addition to other clinical features has significant potential to increase the performance of mortality and length of stay (LOS) models. We evaluate the two different drug representation methods (Extended-Connectivity Fingerprint-ECFP and SMILES-Transformer embedding) on clinical outcome predictions. The results have shown that the proposed multimodal approach achieves substantial enhancement on clinical tasks over baseline models. Using clinical drug representations as additional features improve the LOS prediction for Area Under the Receiver Operating Characteristics (AUROC) around %6 and for Area Under Precision-Re
The integration of Large Language Models (LLMs) into the drug discovery and development field marks a significant paradigm shift, offering novel methodologies for understanding disease mechanisms, facilitating drug discovery, and optimizing clinical trial processes. This review highlights the expanding role of LLMs in revolutionizing various stages of the drug development pipeline. We investigate how these advanced computational models can uncover target-disease linkage, interpret complex biomedical data, enhance drug molecule design, predict drug efficacy and safety profiles, and facilitate clinical trial processes. Our paper aims to provide a comprehensive overview for researchers and practitioners in computational biology, pharmacology, and AI4Science by offering insights into the potential transformative impact of LLMs on drug discovery and development.
Background The cost of drug discovery and development is substantial, with clinical trial outcomes playing a critical role in regulatory approval and patient care. However, access to large-scale, high-quality clinical trial outcome data remains limited, hindering advancements in predictive modeling and evidence-based decision-making. Methods We present the Clinical Trial Outcome (CTO) benchmark, a fully reproducible, large-scale repository encompassing approximately 125,000 drug and biologics trials. CTO integrates large language model (LLM) interpretations of publications, trial phase progression tracking, sentiment analysis from news sources, stock price movements of trial sponsors, and additional trial-related metrics. Furthermore, we manually annotated a dataset of clinical trials conducted between 2020 and 2024 to enhance the quality and reliability of outcome labels. Results The trial outcome labels in the CTO benchmark agree strongly with expert annotations, achieving an F1 score of 94 for Phase 3 trials and 91 across all phases. Additionally, benchmarking standard machine learning models on our manually annotated dataset revealed distribution shifts in recent trials, unders
The depth of knowledge offered by post-genomic medicine has carried the promise of new drugs, and cures for multiple diseases. To explore the degree to which this capability has materialized, we extract meta-data from 356,403 clinical trials spanning four decades, aiming to offer mechanistic insights into the innovation practices in drug discovery. We find that convention dominates over innovation, as over 96% of the recorded trials focus on previously tested drug targets, and the tested drugs target only 12% of the human interactome. If current patterns persist, it would take 170 years to target all druggable proteins. We uncover two network-based fundamental mechanisms that currently limit target discovery: preferential attachment, leading to the repeated exploration of previously targeted proteins; and local network effects, limiting exploration to proteins interacting with highly explored proteins. We build on these insights to develop a quantitative network-based model of drug discovery. We demonstrate that the model is able to accurately recreate the exploration patterns observed in clinical trials. Most importantly, we show that a network-based search strategy can widen the
The competency of any intelligent agent is bounded by its formal account of the world in which it operates. Clinical AI lacks such an account. Existing frameworks address evaluation, regulation, or system design in isolation, without a shared model of the clinical world to connect them. We introduce the Clinical World Model, a framework that formalizes care as a tripartite interaction among Patient, Provider, and Ecosystem. To formalize how any agent, whether human or artificial, transforms information into clinical action, we develop parallel decision-making architectures for providers, patients, and AI agents, grounded in validated principles of clinical cognition. The Clinical AI Skill-Mix operationalizes competency through eight dimensions. Five define the clinical competency space (condition, phase, care setting, provider role, and task) and three specify how AI engages human reasoning (assigned authority, agent facing, and anchoring layer). The combinatorial product of these dimensions yields a space of billions of distinct competency coordinates. A central structural implication is that validation within one coordinate provides minimal evidence for performance in another, re
The role of Artificial Intelligence (AI) is growing in every stage of drug development. Nevertheless, a major challenge in drug discovery AI remains: Drug pharmacokinetic (PK) and Drug-Target Interaction (DTI) datasets collected in different studies often exhibit limited overlap, creating data overlap sparsity. Thus, data curation becomes difficult, negatively impacting downstream research investigations in high-throughput screening, polypharmacy, and drug combination. We propose xImagand-DKI, a novel SMILES/Protein-to-Pharmacokinetic/DTI (SP2PKDTI) diffusion model capable of generating an array of PK and DTI target properties conditioned on SMILES and protein inputs that exhibit data overlap sparsity. We infuse additional molecular and genomic domain knowledge from the Gene Ontology (GO) and molecular fingerprints to further improve our model performance. We show that xImagand-DKI-generated synthetic PK data closely resemble real data univariate and bivariate distributions, and can adequately fill in gaps among PK and DTI datasets. As such, xImagand-DKI is a promising solution for data overlap sparsity and may improve performance for downstream drug discovery research tasks. Code
With increasing interest in adaptive clinical trial designs, challenges are present to drug supply chain management which may offset the benefit of adaptive designs. Thus, it is necessary to develop an optimization tool to facilitate the decision making and analysis of drug supply chain planning. The challenges include the uncertainty of maximum drug supply needed, the shifting of supply requirement, and rapid availability of new supply at decision points. In this paper, statistical simulations are designed to optimize the pre-study medication supply strategy and monitor ongoing drug supply using real-time data collected with the progress of study. Particle swarm algorithm is applied when performing optimization, where feature extraction is implemented to reduce dimensionality and save computational cost.
We introduce SoftTiger, a clinical large language model (CLaM) designed as a foundation model for healthcare workflows. The narrative and unstructured nature of clinical notes is a major obstacle for healthcare intelligentization. We address a critical problem of structuring clinical notes into clinical data, according to international interoperability standards. We collect and annotate data for three subtasks, namely, international patient summary, clinical impression and medical encounter. We then supervised fine-tuned a state-of-the-art LLM using public and credentialed clinical data. The training is orchestrated in a way that the target model can first support basic clinical tasks such as abbreviation expansion and temporal information extraction, and then learn to perform more complex downstream clinical tasks. Moreover, we address several modeling challenges in the healthcare context, e.g., extra long context window. Our blind pairwise evaluation shows that SoftTiger outperforms other popular open-source models and GPT-3.5, comparable to Gemini-pro, with a mild gap from GPT-4. We believe that LLMs may become a step-stone towards healthcare digitalization and democratization.
Clinical NLP increasingly relies on electronic health record (EHR) data to detect suicidal behaviors, treating clinical documentation as more reliable ground truth than social media. We argue that this framing obscures how EHR-based suicidality datasets encode a particular operationalization of suicidality, shaped by who authors the data, how episodes are bounded, and how ambiguity is resolved. We ground this argument in a case study of the ScAN dataset, built over MIMIC-III clinical notes. We show how governance constraints, ICD-based cohort selection, single-annotator labeling, and hospital-stay-level aggregation produce labels that reflect clinician-documented judgments, treat suicidality as a bounded episode, and assume that intent can be reliably inferred from documentation. A linguistic analysis demonstrates that identical labels subsume heterogeneous clinical framings differing in temporality, negation, and uncertainty. We argue that clinical NLP should examine the assumptions embedded in suicidality datasets before interpreting their labels as ground truth.
We introduce Clinical ModernBERT, a transformer based encoder pretrained on large scale biomedical literature, clinical notes, and medical ontologies, incorporating PubMed abstracts, MIMIC IV clinical data, and medical codes with their textual descriptions. Building on ModernBERT the current state of the art natural language text encoder featuring architectural upgrades such as rotary positional embeddings (RoPE), Flash Attention, and extended context length up to 8,192 tokens our model adapts these innovations specifically for biomedical and clinical domains. Clinical ModernBERT excels at producing semantically rich representations tailored for long context tasks. We validate this both by analyzing its pretrained weights and through empirical evaluation on a comprehensive suite of clinical NLP benchmarks.
Introduction: Semantic search, which retrieves documents based on conceptual similarity rather than keywords, offers advantages for retrieval of clinical information. However, deploying semantic search across health systems, comprising hundreds of millions of clinical notes, presents formidable engineering, cost, and governance challenges that have prevented institutional adoption. Methods: We deployed a semantic search system at a large children's hospital indexing 166 million clinical notes (484 million embedding vectors) from 1.68 million patients. The system uses instruction-tuned qwen3-embedding-0.6B embeddings, stores vectors with storage-optimized indexing, maintains full-text metadata in a low-latency key-value store, and operates within a HIPAA-compliant governance framework. We evaluated the system by optimizing the model and chunking strategy using a physician-authored benchmark, characterizing full-scale performance (cost, latency, retrieval quality), and assessing clinical utility via chart abstraction efficiency and comparison to ICD-10 cohort generation. Results: The system delivers sub-second query latency with monthly operational costs of ~USD 4,000. Qwen3 embeddin
Developing AI models that are useful in clinical practice, requires efficient collaboration between clinicians and AI developers. This poses a practical challenge: clinicians must repeatedly communicate and refine their requirements with AI developers before those requirements can be translated into executable model development. This iterative process is time-consuming, and even after repeated discussion, misalignment may still exist because the two sides do not fully share each other's expertise. Coding agents may help close this gap. They can write and refine code on their own, and they carry working knowledge of both medicine and AI to understand commands formulated by both medical experts and developers. We present a prototype that lets clinicians drive AI development directly. A clinician describes the task in plain language, and the system turns the description into a working pipeline, refines it through repeated experiments together with the clinician, and returns a model that meets the stated clinical objective. Across five clinical tasks, the system reliably produces models that matched the clinician's request and reached competitive performance. Most notably, on chest rad